1851634729 NPI number — BETHEL BURRIS OLIVER PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851634729 NPI number — BETHEL BURRIS OLIVER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BETHEL BURRIS OLIVER PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ARKANSAS DENTISTRY AND BRACES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1851634729
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4375 N VANTAGE DRIVE
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72703-5128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-445-6335
Provider Business Mailing Address Fax Number:
479-301-2878

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4605 S PHOENIX AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72903-1713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-782-7080
Provider Business Practice Location Address Fax Number:
479-782-7072
Provider Enumeration Date:
03/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BURRIS
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
479-782-7080

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3339 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: 3460 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223S0112X , with the licence number: 4013 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X , with the licence number: 3465 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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